# HA-0885 - Percentage Worksheet13 - Monthly

```HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
PO Box 299
Trenton, NJ 08625-0299
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
For Health Benefit Contributions under Chapter 78, P.L. 2011
(State Monthly Employees — Not Paid through Centralized Payroll)
Use this worksheet and the attached charts to calculate your combined Health Benefit Contribution.
1.
Use the SHBP Premium Rate Chart and enter the premium amount for
2.
Use the Percentage of Premium Chart for your Level of Coverage to
3.
Calculate your Medical Plan Contribution: Multiply the Medical Plan
CURRENT YEAR
PHASE-IN AMOUNT
NEXT YEAR
PHASE-IN AMOUNT
\$
\$
%
\$
%
\$
(For example: If NJ DIRECT15, Family coverage is \$1,375.85 per month, and your premium percentage is 10.0%;
the calculation is \$1,375.85 X 0.10 = \$137.58 per month.)
4.
Use the SHBP Premium Rate Chart and enter the premium amount for
the SHBP Prescription Drug Plan associated with your Medical Plan at
\$
\$
5.
Use the Percentage of Premium Chart for your Level of Coverage to
6.
Calculate any Prescription Drug Plan Contribution: Multiply the
\$
\$
7.
Add Line #3 and Line #6.
(Medical Plan Contribution + Prescription Drug Plan Contribution)
\$
\$
\$
\$
%
%
Calculate Minimum Required Contribution
Employees must pay a minimum of 1.5% of Annual Salary
8.
9.
Multiply your Annual Salary by 1.5% (Salary X 0.015).
10.
This is your 1.5% Minumum annual percentage of salary.
11.
Divide the annual amount on Line #10 by 12 months.
12.
This is the minimum monthly amount you are required to contribute.
X 0.015
\$
X 0.015
\$
&divide; 12
&divide; 12
\$
\$
\$
\$
13.
If the amount on Line #7 is larger than the amount on Line #12, enter it
here. Otherwise, enter the amount on Line #12.
Required Contribution
The calculations from this worksheet are approximations
and may differ from the actual amounts deducted from payroll.
HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
STATE MONTHLY ACTIVE GROUP
MONTHLY RATES EFFECTIVE 1/1/2013 to 12/31/2013
PLAN/COVERAGE
DESCRIPTION
MONTHLY
TOTAL
MEDICAL PLANS AVAILABLE WITH PRESCRIPTION DRUG PROGRAM #203
AETNA FREEDOM15 #180(1)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$597.98
\$1,195.95
\$1,494.94
\$896.97
NJ DIRECT15 - #150(1)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$592.06
\$1,184.11
\$1,480.14
\$888.09
AETNA HMO #005)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$602.91
\$1,205.82
\$1,507.29
\$904.37
HORIZON HMO #011(1)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$596.88
\$1,193.76
\$1,492.22
\$895.32
PRESCRIPTION DRUG PROGRAM - #203
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$164.78
\$329.56
\$411.96
\$247.17
MEDICAL PLANS AVAILABLE WITH PRESCRIPTION DRUG PLAN #205
AETNA FREEDOM1525 #063(2)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$581.23
\$1,162.47
\$1,453.09
\$871.85
NJ DIRECT1525 #051(2)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$575.48
\$1,150.96
\$1,438.70
\$863.22
AETNA HMO1525 #061(2)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$586.03
\$1,172.06
\$1,465.08
\$879.05
HORIZON HMO1525 #053(2)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$580.17
\$1,160.34
\$1,450.43
\$870.26
PRESCRIPTION DRUG PROGRAM #205
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$149.46
\$298.91
\$373.65
\$224.19
HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
STATE MONTHLY ACTIVE GROUP
MONTHLY RATES EFFECTIVE 1/1/2013 to 12/31/2013
PLAN/COVERAGE
DESCRIPTION
MONTHLY
TOTAL
MEDICAL PLANS AVAILABLE WITH PRESCRIPTION DRUG PROGRAM #206
AETNA FREEDOM2030 #064(3)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$546.55
\$1,093.10
\$1,366.38
\$819.83
NJ DIRECT2030 #052(3)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$541.14
\$1,082.28
\$1,352.85
\$811.71
AETNA HMO2030 #062(3)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$551.06
\$1,102.12
\$1,377.66
\$826.59
HORIZON HMO2030 #054(3)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$545.55
\$1,091.10
\$1,363.88
\$818.33
PRESCRIPTION DRUG PROGRAM #206
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$152.10
\$304.18
\$380.23
\$228.15
HIGH DEDUCTIBLE HEALTH PLANS WITH BUILT IN PRESCRIPTION DRUG
AETNA VALUE HD4000 #092(4)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$422.18
\$844.37
\$1,055.47
\$633.27
NJ DIRECT HD4000 #090(4)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$401.93
\$803.87
\$1,004.84
\$602.90
AETNA VALUE HD1500 #093(5)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$601.14
\$1,227.30
\$1,540.38
\$914.22
NJ DIRECT HD1500 #091(5)
Single
Member &amp; Spouse/Partner
Family
Parent &amp; Child
\$571.12
\$1,167.24
\$1,465.31
\$869.19
1)Subscribers in # 150,#180,#005, &amp; #011are subject to \$15 Primary Care and \$15 Specialist office visit co pay and are eligible for Prescription Drug
Plan #203
2)Subscribers in #051,#061, #53 &amp; #063 are subject to \$15 Primary Care and \$25 Specialist office visit co pay and are eligible for Prescription Drug
Plan #205
3)Subscribers in # 052,#062, #54 &amp; #064 are subject to \$20 Primary Care and \$30 adult/\$20 child Specialist office visit co pay and are eligible for
Prescription Drug Plan #206
4)Subscribers in High Deductible Plans #90, #92, are subject to \$4,000 In-Network deductible
5)Subscribers in High Deductible Plans #91 and #93, are subject to \$1,500 In-Network deductible
6)For Subscribers in High Deductible Plans #093 and #091, employer will contribute \$300 annually to Health Savings Account
HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
For Health Benefit Contributions under Chapter 78, P.L. 2011
Note: The following charts reflect the phaseͲin of contribution levels for employees employed on the
contribution’s effective date who will pay &frac14;, &frac12;, &frac34; and the full amount of the contribution rate during the
phaseͲin years.
New employees hired on or after June 28, 2011, the effective date of Chapter 78, P.L. 2011, contribute
at the highest percentage level (Year 4).
HEALTH BENEFITS CONTRIBUTION FOR SINGLE COVERAGE
Four Year PhaseͲIn
Salary Range
Use dates indicated or as otherwise determined by contract
Year 1
July 2011 to
June 2012
Year 2
July 2012 to
June 2013
Year 3
July 2013 to
June 2014
Year 4
July 2014 and
after
less than 20,000
1.13%
2.25%
3.38%
4.50%
20,000Ͳ24,999.99
1.38%
2.75%
4.13%
5.50%
25,000Ͳ29,999.99
1.88%
3.75%
5.63%
7.50%
30,000Ͳ34,999.99
2.50%
5.00%
7.50%
10.00%
35,000Ͳ39,999.99
2.75%
5.50%
8.25%
11.00%
40,000Ͳ44,999.99
3.00%
6.00%
9.00%
12.00%
45,000Ͳ49,999.99
3.50%
7.00%
10.50%
14.00%
50,000Ͳ54,999.99
5.00%
10.00%
15.00%
20.00%
55,000Ͳ59,999.99
5.75%
11.50%
17.25%
23.00%
60,000Ͳ64,999.99
6.75%
13.50%
20.25%
27.00%
65,000Ͳ69,999.99
7.25%
14.50%
21.75%
29.00%
70,000Ͳ74,999.99
8.00%
16.00%
24.00%
32.00%
75,000Ͳ79,999.99
8.25%
16.50%
24.75%
33.00%
80,000Ͳ94,999.99
8.50%
17.00%
25.50%
34.00%
95,000 and over
8.75%
17.50%
26.25%
35.00%
* Member contribution is a minimum of 1.5% of base salary towards Health Benefits
HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
HEALTH BENEFITS CONTRIBUTION FOR FAMILY COVERAGE
Four Year PhaseͲIn
Salary Range
Use dates indicated or as otherwise determined by contract
Year 1
July 2011 to
June 2012
Year 2
July 2012 to
June 2013
Year 3
July 2013 to
June 2014
Year 4
July 2014 and
after
less than 25,000
0.75%
1.50%
2.25%
3.00%
25,000Ͳ29,999.99
1.00%
2.00%
3.00%
4.00%
30,000Ͳ34,999.99
1.25%
2.50%
3.75%
5.00%
35,000Ͳ39,999.99
1.50%
3.00%
4.50%
6.00%
40,000Ͳ44,999.99
1.75%
3.50%
5.25%
7.00%
45,000Ͳ49,999.99
2.25%
4.50%
6.75%
9.00%
50,000Ͳ54,999.99
3.00%
6.00%
9.00%
12.00%
55,000Ͳ59,999.99
3.50%
7.00%
10.50%
14.00%
60,000Ͳ64,999.99
4.25%
8.50%
12.75%
17.00%
65,000Ͳ69,999.99
4.75%
9.50%
14.25%
19.00%
70,000Ͳ74,999.99
5.50%
11.00%
16.50%
22.00%
75,000Ͳ79,999.99
5.75%
11.50%
17.25%
23.00%
80,000Ͳ84,999.99
6.00%
12.00%
18.00%
24.00%
85,000Ͳ89,999.99
6.50%
13.00%
19.50%
26.00%
90,000Ͳ94,999.99
7.00%
14.00%
21.00%
28.00%
95,000Ͳ99,999.99
7.25%
14.50%
21.75%
29.00%
100,000Ͳ109,999.99
8.00%
16.00%
24.00%
32.00%
110,000 and over
8.75%
17.50%
26.25%
35.00%
*Member contribution is a minimum of 1.5% of base salary towards Health Benefits
HA-0885-0912
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
STATE HEALTH BENEFITS PROGRAM
HEALTH BENEFITS CONTRIBUTION FOR
MEMBER/SPOUSE/PARTNER OR PARENT/CHILD COVERAGE
Four Year PhaseͲIn
Salary Range
Use dates indicated or as otherwise determined by contract
Year 1
July 2011 to
June 2012
Year 2
July 2012 to
June 2013
Year 3
July 2013 to
June 2014
Year 4
July 2014 and
after
less than 25,000
0.88%
1.75%
2.63%
3.50%
25,000Ͳ29,999.99
1.13%
2.25%
3.38%
4.50%
30,000Ͳ34,999.99
1.50%
3.00%
4.50%
6.00%
35,000Ͳ39,999.99
1.75%
3.50%
5.25%
7.00%
40,000Ͳ44,999.99
2.00%
4.00%
6.00%
8.00%
45,000Ͳ49,999.99
2.50%
5.00%
7.50%
10.00%
50,000Ͳ54,999.99
3.75%
7.50%
11.25%
15.00%
55,000Ͳ59,999.99
4.25%
8.50%
12.75%
17.00%
60,000Ͳ64,999.99
5.25%
10.50%
15.75%
21.00%
65,000Ͳ69,999.99
5.75%
11.50%
17.25%
23.00%
70,000Ͳ74,999.99
6.50%
13.00%
19.50%
26.00%
75,000Ͳ79,999.99
6.75%
13.50%
20.25%
27.00%
80,000Ͳ84,999.99
7.00%
14.00%
21.00%
28.00%
85,000Ͳ99,999.99
7.50%
15.00%
22.50%
30.00%
100,000 and over
8.75%
17.50%
26.25%
35.00%
*Member contribution is a minimum of 1.5% of base salary towards Health Benefits
```